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Economy Brings Back Nursing Home Staffing Debate

With money tight, lawmakers are looking at changing the way the number of hours of mandatory daily care for nursing home patients is counted, reducing the number of required hours of care by certified nursing assistants, and having registered nurses pick up some of that care.

Nursing homes and other backers of the idea say the move will improve care, by having more skilled nurses responsible for the regular care of residents. But opponents, lead by the union that represents most nursing assistants, say registered nurses have lots to do already, and aren't able to actually give residents much hands-on assistance, and that means their care will suffer.

The Medicaid budget conforming bills in the House and the Senate change the way the hourly nursing requirements for residents are calculated.

The standards for how many hours per day nursing home residents must receive from certified nurses assistants were set in 2001 as part of a deal involving lawsuit rules struck between advocates for the residents and consumer groups on one side and the industry on the other. As part of the compromise, lawsuit damages were limited, and other changes were made to protect homes from unwarranted litigation. In exchange, staffing requirements were ramped up so that in 2007 the number of hours per day that CNAs had to spend with patients increased to 2.9 per day, figured on a weekly average. CNAs typically do the routine hands on care in homes, such as turning and bathing patients.

Late last week, the Senate Ways and Means Committee voted out its version of the legislation (SB 1464), which, while keeping the staffing levels at 2.9 hours per day, allows a “blended” way of calculating how that number is reached, counting time spent by nurses who are already in the facilities anyway. The hours of care actually done by CNAs amount to 2.7 per day under the proposed new system.

“We are not talking about reducing direct care by the bedside,” LuMarie Polivka-West, senior director of policy for the Florida Health Care Association, which represents nursing home owners, told the Ways and Means Committee. “We're talking about giving flexibility to the nursing home.”

Polivka-West reminded the panel that the 2.9 hour standard is more than is recommended as the industry standard by federal officials and more than most other states - there is no federal minimum. And it's required even as state lawmakers have cut the amount of money nursing homes get from Medicaid for each patient they treat.

The Senate is proposing a $200 million cut this year in nursing home reimbursement, while the House proposed a $133 million reduction. Nursing home owners say they've lost money for years on Medicaid patients with the higher staffing requirements coupled with lower reimbursement rates.

But certified nursing assistants argue the current system has worked, and that under the new way of figuring the hours, care will suffer.

Jean Berg, a certified nursing assistant at Spring Hill Health and Rehabilitation in Brooksville told the Ways and Means Committee last week that the nurses she works with just don't have the time to do additional non-medical bedside care, like bathing.

“Nurses in my building have 20 patients, she's on a thin line with responsibilities,” Berg said. “They're two different jobs. The CNA is the caregiver.” She argues that the additional care from nurses will simply never materialize.

Sen. Joe Negron, R-Stuart, said the law will require that the nurses do take part in the care - that homes won't have an ability to skirt the requirement.

“They have to add in nursing care,” said Negron. “This is not writing things down. It must be bedside care, taking care of patients.”

Sen. Eleanor Sobel, D-Hollywood, introduced an amendment last week to try to maintain current law, but withdrew it when it was clear the amendment would have failed had it come to a vote in the Ways and Means Committee.

The sponsor of the Medicaid bill in the Senate, Health and Human Services Appropriations Chairman Durell Peaden, R-Crestview, argues that bringing nurses into the requirement will make care better.

“They're additional workforce capabilities ... these people will not be without the bedside care we had in 2.9, they'll be exposed to LPNs or RNs,” said Peaden. “The important thing is the patient ... not the nurse, not what hat she wears.”

The AARP, which was heavily involved in the 2001 deal that led to the increased staffing requirements, has asked the Legislature to make any change in the way staffing is calculated be made temporary, though so far, no move has been made to do that in the legislation, which could be considered on the floors of both chambers as early as this week.

“Everything's temporary in the Legislature,” noted Peaden. But, he said, “I'm very comfortable with what we're trying to do here.”

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